R-0145 111
G PERMIT R_ O I �[
APPLICATION FOR CITY OF CUPERTINL1�180
NUMBER J
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF' Y - T ISUANCE OR
DAYSFROM LAST CALLEDSNSPECTION.
BUILDING ADDRESS 7,�Y!/Jj uvO ` /Z, s� � _ r'" BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/- HAZARDOUS ROOF
NAME -•67.4i1 /h i Mo:4/1 Yo FIRE COVERING
AREA CLASS
ADDRESS 7Cl S�/O elafZCIL1nizlc EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
..� s TO BE REMOVED TO BE RETAINED
NAME /Z.aN IG "?/?f Ael a ✓/ Cl y'r TYPE OF ROOF COVERINGADDRESS
,
ti Ct
CITY &ZIP ��746 l,� 3-;,� -F f
e .vEy /�/! EXISTING
PHONE 2 7 9 57e f .BUILT-UP ROOF
LICENSE ASPHALT SHINGLES A/
NUMBER p '
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
with S affirm that of licensed under a Business
of Chapters(coons Coda,
Cling with section 7000) of Dunston 3 of the egsmess ana Professions cont, WOOD SHINGLES
anemy manse is in f ro.Ca and aueC'.
License Class Lic.Number relevi /
Date ContractorOTHER (SPECIFY)
WNER BUILDER DECLARATION
I hereby affirm that I a exempt from the Contractors License Law for
the following reason.
(Sec.731.5, Business and Prof fzions code: Any city PROPOSED
Or county which req u res a permit to construct, alter, improve, dem Olizh,or
repair any structure, prior to Its issuance,also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
r' of me Contractor is License Law(Chapter 9 (commencing with Section 7000)
* Of Division 3 of the Business and Professions conal or met he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any,applicant for a permit;�. ubjects In.applicant to a civil penalty of not more that five hundred dollars WOOD SHAKES
I
T C] I,as owner Of the property, ormy employees with wages as their sole
compensation,mpensation,will do me work,and the structure is not intended or offered
rWOOD SHINGLES
or sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply 10 on owner Or properly who build,Or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended oroffered for sale. If, however, me OTHER (SPECIFY)
building o mprovement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for
purpose of sant.). .PROVIDE LC:B.O. REPORT N0.
D I, a r Of the property, a exclusively contracting with.licensetl
contractors to construct the project (Sec. 7044, Business and Professions !r
cde: The Contractor's License Law does not apply to an owner'of property PROVIDE MFGR. INSTALLATIONISPECS.
h builds or improves thereon,and An contracts for such projects with a
norlsl licensed pursuant to he Contractor's License Law.re _
I am exempt under Sec. ,B.a P.C.for this FASTENER
�_:Data W KE OM ENSATION DECLARATION
I hereby affirm that I have a certificate of Consent to self insure,or a car TYPE
tificate of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.C.).
Policy NO. Company
0 eerwiad Copy Is hereby furnished' LENGTH
Certified copy is filed with the City inspection division.
Applicant `- FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS' )
COMPENSATION B millet (NSU a NCE
perm s�7�
1 (This($ 0 suction valid not be completed if iM1e permit is for one hundred not.
t` Iarz Is1o0)or that
i; VALUATION�U
certify mat in the performance or the work for which this permit is
\ issued, I shall not employ any person in any manner so as to become subject
to me Workers'Compensation Laws of California.
Date - -Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE
you should become
subject to the Workers' Compensation provisions of,the
Labor Code, you must forthwith comply with such provisions or this permit
shall be deemed revoked. ,y /DA4E0 APPLICATION
I certify that I nave read this application and state that the above informs
tion is correct. 1 agroe to comply with all city and county ordinances and `I
state laws relating to building construction, and hereby authorize represen-
tatives Of this city 10 enter upon the above mentioned property for inspection
purposes. 1
IWa) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in Consequence of the granting of this permit. �" p
.- Z/.S/sre- �f—
fal
j• '-
Ilk.
S nature of,Appllcent/ actd� Date r�-�r�—
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS hINSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY